Purpose To know which sperm selection technique, physiological intracytoplasmic sperm injection (PICSI) or magneticactivated cell sorting (MACS), is better for the selection of sperm with abnormal sperm DNA fragmentation (SDF) in patients undergoing intracytoplasmic sperm injection (ICSI). Methods A prospective randomized trial included 413 ICSI cases with abnormal SDF (> 20.3%) by TUNEL assay. Patients with at least 1 million total progressive motile sperm count were randomized to PICSI or MACS groups on the day of ICSI. PICSI depends on the hyaluronan binding of better SDF sperm where individual sperm was selected, while MACS selects nonapoptotic sperm population using Annexin V magnetic beads. All pre-implantation embryogenic parameters were observed and the main outcome was the ongoing pregnancy rate. Results There were no significant differences between patients allocated to PICSI and MACS in the studied parameters including pre-implantation embryological data, implantation, clinical pregnancy, and ongoing pregnancy rates. Meanwhile, sub-analysis according to the female age has shown that female patients with less than 30 years of age in the MACS group had significantly higher good-quality blastocyst, clinical pregnancy, and ongoing pregnancy rates than the PICSI group. However, the higher implantation (p = 0.051), clinical pregnancy (p = 0.078), and ongoing pregnancy (p = 0.097) rates observed in females between 30 and 35 years of age in the PICSI group did not reach significance level. Conclusions PICSI and MACS are efficient techniques for sperm selection in cases with abnormal sperm DNA fragmentation. However, MACS is preferred when the females are younger than 30 years, while PICSI is preferred in older females. Clinical trial registration number NCT03398317 (retrospectively registered)

Non-DUC p N 2 2 9 2 Patient/Cycle Characteristics (M ± SD) Age at retrieval 35.9 AE 3.5 35.9 AE 3.3 0.95 BMI 26.1 AE 5.4 28.3 AE 5.9 0.12 Eggs retrieved 14.4 AE 8.0 15.7 AE 8.2 0.51 Endometrial thickness (mm) 9.6 AE 1.4 9.9 AE 1.9 0.54 LB rates Overall 31.8% 70.7% <0.01 By developmental day Day 5 45.5% (11) 72.9% (70) 0.08 Day 6 18.2% (11) 63.6% (22) <0.05 By morphology Good 66.7% (3) 75.0% (36) 0.31 Fair 35.7% (14) 70.6% (51) <0.05 Poor 0% (5) 40.0% (5) 0.44 Number of blastocysts transferred shown in parentheses